title: Prolonged waiting times for liver transplantation in obese patients.
abstract: OBJECTIVE
  To quantify the independent association between obesity and access to liver transplantation.
  
  
  BACKGROUND
  Obesity is associated with higher complication rates, longer hospitalization, and worse survival after liver transplantation. Nevertheless, transplantation provides survival benefit to patients with end-stage liver disease, regardless of body mass index (BMI). We hypothesized that, despite survival benefit, providers were reluctant to transplant obese patients because of the inherent difficulty of these cases and their inferior outcomes. Our goal was to quantify the independent association between BMI and waiting time for orthotopic liver transplantation as a surrogate marker for this reluctance.
  
  
  METHODS
  We studied 29,136 wait-list candidates in the model for end-stage liver disease (MELD) era, categorized as severely obese (BMI 35-40), morbidly obese (BMI 40-60), and reference (BMI 18.5-35). All models were adjusted for factors relevant to the allocation system, factors possibly influencing access to healthcare, and factors biologically related to disease progression and outcomes.
  
  
  RESULTS
  The odds of receiving a MELD exception were 30% lower in severely obese and 38% lower in morbidly obese patients. Similarly, the likelihoods of being turned down for an organ were 10% and 16% higher, and the rates of being transplanted were 11% and 29% lower in severely obese and morbidly obese patients, respectively.
  
  
  CONCLUSIONS
  Current practice seems to indicate a reluctance to transplant obese patients. If indeed as a community we feel that liver allografts should not be distributed to patients with excessive postoperative risk, we should consider expressing this as a formal change to our allocation policy rather than through informal practice patterns.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. dorry@jhmi.edu
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.forename: Richard E
authors.initials: RE
authors.lastname: Thompson
authors.forename: Jayme E
authors.initials: JE
authors.lastname: Locke
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Simpkins
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Thuluvath
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Warren R
authors.initials: WR
authors.lastname: Maley
mesh_terms: D015992:Body Mass Index; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D005234:Fatty Liver / Q000453:epidemiology / Q000601:surgery; D005260:Female; D006297:Health Services Accessibility; D006526:Hepatitis C / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D017093:Liver Failure / Q000453:epidemiology* / Q000601:surgery; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology*; D009767:Obesity, Morbid / Q000453:epidemiology; D018579:Patient Selection; D012044:Regression Analysis; D040841:Resource Allocation / Q000458:organization & administration; D009927:Tissue and Organ Procurement / Q000458:organization & administration* / Q000706:statistics & numerical data; D014850:Waiting Lists